Burnout Starts Early, Especially in Some Specialties

Tara Haelle

September 18, 2018

Nearly half of residents report burnout during their second year of residency, and 1 in 7 report regretting their career choice, according to a prospective study published online today in JAMA. However, not all specialties are equally affected by burnout or regret, the authors report.

Despite the high prevalence of burnout among residents, a systematic review published in the same issue finds that studies of physician burnout vary so greatly in their definitions and measurement tools that little can be concluded about the overall prevalence of burnout among physicians in general.

The review of 182 studies worldwide found physician burnout rates range from 0% to more than 85%, depending on definitions and cutoffs of burnout measurement.

In the study on residents, Liselotte N. Dyrbye, MD, MHPE, of the Mayo Clinic, and colleagues prospectively tracked 4696 US resident physicians from 49 medical schools for up to 6 years starting from their first year in medical school. First-year students filled out a baseline questionnaire between October 2010 and January 2011 and then two more questionnaires in their fourth school year and their second year of residency.

The questionnaires collected information on participants' demographics, clinical specialty, educational debt, and US Medical Licensing Examination Step 1 score. Students also answered questions about their levels of anxiety, empathy, and social support while in medical school; in later surveys, they were asked if they regretted their career choice.

Of the 76.4% of participants (n = 3588) who completed the second-year residency questionnaire, 45% reported burnout symptoms and 14% regretted their career choice.

Burnout prevalence was lowest in dermatology, at 29.6%, and highest in urology, at 63.8%. Rates of burnout were in the middle range among those in primary care specialties, including 42.6% in internal medicine, 37.2% in family medicine, and 43.2% in pediatrics.

In multivariate analyses, compared to internal medicine residents, residents in urology, neurology, emergency medicine, and general surgery were significantly more likely to report symptoms of burnout, depending on their specialty (relative risk [RR], 1.24 - 1.48). In contrast, residents in dermatology and pathology were significantly less likely to report burnout (RR, .62 - .63)

Women were 17% more likely to report burnout symptoms than their male counterparts (RR, 1.17). Dyrbye and colleagues suggest that "difficulties with work-life balance and work-home conflicts, sexism, stereotype threat and discrimination may play a part."

Anxiety appeared to be a risk factor for subsequent burnout. Specifically, for each additional percentage point of anxiety an individual reported in medical school, the risk for burnout symptoms increased by 8%. Empathy emerged as a protective factor, however, with residents having a 1% lower risk for burnout symptoms for each 1-point increase in empathy they reported in medical school.

Both burnout and clinical specialty were significantly linked to regretting career choice in varying amounts, depending on the specialty.

"The clinical specialty areas with the highest prevalence of resident physicians experiencing symptoms of burnout mirrored those of practicing physicians to a large extent," the authors write. "These findings suggest the increased burnout among physicians in these specialties may be attributable, in part, to unique characteristics of the work intrinsic to these specialties."

Burnout Poorly Defined

For the systematic review, Lisa S. Rotenstein, MD, MBA, of Harvard Medical School in Boston, and colleagues searched EMBASE, ERIC, MEDLINE/PubMed, psycARTICLES, and psycINFO and identified 182 studies published on physician burnout prevalence between 1991 and June 2018. The studies involved 109,628 people in 45 countries; 86% of the studies used the Maslach Burnout Inventory (MBI) to measure burnout.

Two thirds of the studies reported on overall burnout, and 63% to 72% reported variably on emotional exhaustion, depersonalization, and low personal accomplishment.

However, the studies used 142 unique definitions for criteria description and varying score cutoffs to classify burnout, "indicating substantial disagreement in the literature on what constituted burnout," the authors write. Even among studies relying on MBI-based tools, at least 47 different definitions of overall burnout prevalence occurred in the literature.

Burnout prevalence ranged from 0% to 80.5%, and similar ranges were reported for prevalence of emotional exhaustion (0% to 86.2%), depersonalization (0% to 89.9%), and reported low personal accomplishment (0% to 87.1%).

"Because of inconsistencies in definitions of and assessment methods for burnout across studies, associations between burnout and sex, age, geography, time, specialty, and depressive symptoms could not be reliably determined," the authors conclude.

In an accompanying editorial, Thomas L. Schwenk, MD, of the University of Nevada School of Medicine in Reno, and Katherine J. Gold, MD, MSW, MS, of the University of Michigan Health System in Ann Arbor, agreed that discussions of burnout have become problematic.

"The term burnout has taken on meaning far beyond what is understood about it as an actual diagnosis or even a syndrome," Schwenk and Gold write. "The medical profession has taken a self-reported complaint of unhappiness and dissatisfaction and turned it into a call for action on what is claimed to be a national epidemic that purportedly affects half to two-thirds of practicing physicians."

Yet this "epidemiological imperative and seemingly self-evident need to act" exist in the absence of reliable information on the actual prevalence of burnout among physicians. The systematic review authors found the studies so heterogeneous that they "abandoned a formal meta-analysis as a viable approach to present the data," Schwenk and Gold write.

"If a construct like burnout is so variable in its prevalence, then either its measures are highly unreliable, or seemingly similar populations differ widely in risk. Both explanations are worthy of study," Schwenk and Gold conclude.

"Simply accepting the oft-quoted statement that 'half of all physicians are burned out' is inappropriate," they continue. "If the risk of burnout varies widely according to location, clinical setting, type of practice, medical specialty and other demographic features, an explanatory model is essential to the understanding of the specific components of these demographic correlates that could lead to interventions."

Both studies were supported by the National Institutes of Health, and the residents study received further funding from the Mayo Clinic Department of Medicine Program on Physician Well-Being. Drs Dyrbye and Shanafelt receive royalties from CWS Inc for the Well-Being Index licensed by the Mayo Clinic. All other authors of the three articles have disclosed no relevant financial relationships.

JAMA. Published online September 18, 2018. Residents study, Abstract; Prevalence study, Abstract; Editorial

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